Health Advantage

Forms for Employers

These forms are in portable document format (PDF). You may print and copy as needed.

Note:

• Groups that submit eligibility electronically or on paper may use these forms.
• Groups that submit electronic enrollment must submit changes to membership information electronically.
• The employee enrollment applications are for use by groups that submit paper enrollment forms only.

Health Advantage Group Administrators

• Active Employee Application for Out-of-Area Classification (PDF) Active Employees of Arkansas-based employer groups that live outside of Arkansas for more than 90 days may have access services covered by Health Advantage on the employee’s group health plan, if approved.
  
  
• Address Change Form (PDF)
  
  
• Billing Adjustment Form (PDF)
  
  
• Blueprint for Employers Registration Form (PDF)
  
  
• Blueprint for Employers Web Administrator Change Form (PDF)
  
  
• Change Request Form (PDF) Use this form to request a change to your current policy, such as name changes, beneficiary change, member termination and more. (Note that this form is used only for groups that submit paper application forms.)
  
  
• Coordination of Benefits Questionnaire (PDF)
  
  
• Dependent Application for Out-of-Area Classification (PDF)
  
  
• Health Benefits Certificate of Coverage (Sample) (PDF)
  
  
• Large Group Employee Application (PDF)
  
  
• Medical Claim Form (PDF)
  
  
• Medical Questionnaire for Late Enrollees (PDF)
  
  
• Newborn Enrollment Request (PDF)
  
  
• Physician Incapacity Letter (PDF)
  
  
• Prescription Claim Form (PDF) This claim form should not be used by CHIP policyholders. Prescription drug claims for CHIP policyholders should be filed using the Medical Claim Form linked above.
  
  
• Primary-Care Physician Selection Letter (PDF)
  
  
• Request for Member Social Security Number (PDF)
  
  
• Small Group Employee Application (PDF)
  
  
• State of Arkansas Continuation of Coverage Election Form (PDF)
  
  
• Subscriber's Incapacity Form (PDF)
  

Arkansas State Employees/Public School Personnel Group Administrators

• Arkansas Employee Benefits Division Forms Find the form you need on the Employee Benefits Division Web site.
  
  
• Other Insurance/Coordination of Benefits (COB) (PDF) Do you have other insurance? Fill out this form, and let us know.